Documenting Trigger Point Injections for Better Reimbursement

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• An integral part of comprehensive pain
  management, trigger point injections are used to
  treat painful areas of muscle that contain
  trigger points, or knots of muscle that form when
  muscles do not relax. Documenting trigger point
  injections is an important part of pain
  management medical billing. Trigger points may
  irritate the nerves around them and cause pain at
  the site of the trigger point or the pain can be
  felt in other parts of the body, including the
  back and neck.

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CPT Codes for Trigger Point Injections

• 20552 Injection(s) single or multiple trigger
  point(s), 1 or 2 muscle(s)
• 20553 Injection(s) single or multiple trigger
  point(s), 3 or more muscles

When repeat trigger point injections are
necessary, the medical record must reflect the
reason for repeated injections. The patients
response to the previous injection is an
important factor in deciding any subsequent
treatments.
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ICD-10 Codes
ICD-10 codes indicating trigger point injections
that the Medicare carrier will reimburse include

• M46.01 Spinal enthesopathy, occipito-atlanto-axia
  l region
• M46.02 Spinal enthesopathy, cervical region
• M46.05 Spinal enthesopathy, thoracolumbar region
• M46.08 Spinal enthesopathy, sacral and
  sacrococcygeal region
• M60.811 Other myositis, right shoulder
• M60.812 Other myositis, left shoulder

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• M60.89 Other myositis, multiple sites
• M76.01 Gluteal tendinitis, right hip
• M76.02 Gluteal tendinitis, left hip
• M76.61 Achilles tendinitis, right leg
• M76.62 Achilles tendinitis, left leg
• M76.821 Posterior tibial tendinitis, right leg
• M76.822 Posterior tibial tendinitis, left leg
• M79.1 Myalgia
• M79.7 Fibromyalgia

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Noridian MAC Policy
AAPM points out Noridian as one of the Medicare
Administrative Contractors (MAC) to update its
policies including LCDs for trigger point
injections, with effect from May 26, 2017. Major
criteria necessary to establish the diagnosis

• Regional pain complaint
• Pain complaint or altered sensation in the
  expected distribution of referred pain from
  a trigger point
• Taut band palpable in an accessible muscle with
  exquisite tenderness at one point along the
  length of it
• Some degree of restricted range of motion, when
  measurable

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According to Noridans policy, only one of four
minor criteria is needed for the diagnosis

• Reproduction of referred pain pattern by
  stimulating the trigger point
• Altered sensation by pressure on the tender spot
• Local response elicited by snapping palpation at
  the tender spot or by needle insertion into
  the tender spot
• Pain alleviated by stretching or injecting the
  tender spot

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Accurate Documentation Critical for Reimbursement
In an article, National Government Services (NGS)
cautions physicians against illegible
documentation and cookie cutter physician notes
which are a typical drawback of some EMR systems,
where all patients are getting the same
procedure, with the same complaint, the same
findings and the provider is treating them all
with the same exact plan of care.
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The NGS article recommends that injection
documentation answers the following questions

• What was the medication and how much was
  injected?
• How was the medication administered?
• Where was it administered?
• Who administered the medication?
• Did the patient have a reaction to the
  medication?
• Was any medication discarded?
• Was it medically necessary?

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Medical Billing Outsourcing - Ensure Appropriate
Reimbursement
Medical billing specialists at the physicians
office must be familiar with the diverse policies
of all MACs which may vary in terms of the
frequency and/or limitation of injections and
documentation requirements. Outsourcing medical
billing to an experienced service provider could
be the best way to ensure accurate coding and
documentation, and avoid the risk of audits.
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